Register your asbestos exposure

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Please note this is a general enquiry form. Completing and submitting this form does not constitute giving Maurice Blackburn instruction to act on your behalf.

Please register your asbestos exposure with Maurice Blackburn's national asbestos database. To be registered on our database, you need to complete all required fields.

Note: * Denotes required fields.

Contact Details

Title
First Name	*
Last Name	*

Address 1	*	BH Phone	*
Address 2		AH Phone	*
Suburb	*	Mobile Phone
State		Fax
Postcode	*	Email	*
Country	*

Date of Birth

Exposure Details

Where were you exposed?

If at work, please enter the name of your employer, your job title and approximate dates of employment.

If other, please explain.

How were you exposed? (E.g. Cutting asbestos sheeting)

If possible, please provide names of two co-workers who can confirm your exposure

Coworker 1 Name

Coworker 1 Address

Coworker 2 Name

Coworker 2 Address

Have you been diagnosed with an asbestos related disease?

Yes

If yes, please indicate which one

Verification

Enter the words shown

Please note this is a general enquiry form. Completing and submitting this form does not constitute giving Maurice Blackburn instruction to act on your behalf.

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